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Developing the evidence for kinesiology-style manual muscle testing: A series of diagnostic test accuracy studies

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Abstract

Introduction Practitioners have used manual muscle testing (MMT) to assess neuromusculoskeletal integrity since early last century [1]. Since the 1960’s, chiropractors began using MMT to detect various other target conditions such as organ, endocrine or immune dysfunction [2]. Subsequently, a third distinct type of MMT has evolved, kinesiology-style MMT (kMMT), commonly referred to as simply “muscle testing.” It differs from the other types in that normally only one muscle (commonly called “the indicator muscle”) is tested repeatedly as the target conditions change. It is estimated that kMMT is practiced in over 70 different technique systems and by over 1 million people worldwide. As a result of this divergence of the practice of MMT/kMMT, there exists some confusion surrounding the term itself, and how the tests are performed and interpreted. Consequently, research efforts to assess its validity and clinical utility have been difficult to design, to conduct and even to understand; and as a result, its usefulness as an assessment method has been called into question [3-6]. This paper describes a series of diagnostic test accuracy studies aimed at developing evidence for one application of kMMT: distinguishing true from false spoken statements. The main objectives of Studies 1 and 2 were to estimate the accuracy (overall fraction correct) of this application of kMMT while the objective of Study 3 was to compare these results with grip strength dynamometry. Methods Three prospective studies of diagnostic test accuracy were carried out where kMMT practitioners and kMMT-naïve test patients (TPs) were recruited. TPs were shown pictures (via computer) and instructed (via headset) to make simple true or false statements about the picture, after which the muscle test was performed. The reference standard was the statements’ actual verity and the index test was kMMT. A secondary index test was also enacted in alternating blocks: practitioners were asked to “guess” the verity of the spoken statement without using kMMT, merely relying on visual, auditory and kinesthetic clues. In Study 1 (n=48 practitioner-TP pairs), each practitioner performed 40 kMMTs broken up into blocks of 10 which alternated with 4 blocks of 10 guesses. Study 2 (n=20 pairs) replicated Study 1. Study 3 (n=20 TPs) removed the influence of practitioners by using a grip-strength dynamometer to measure muscle strength following the spoken statement in 4 blocks of 5 grip strength tests. In Studies 1 and 2, overall fraction correct was calculated for each pair, and the overall mean reported. In Study 3, the mean grip strength after false statements was compared to the mean grip strength after true statements was compared. Results In Study 1 kMMT practitioners correctly distinguished lies from truth in 69.3% (95% confidence interval [CI] 66.0-72.5%) of statements more often than by chance alone (p<0.01), or guessing (47.4% accuracy; 95% CI 0.449 - 0.500). In Study 2, kMMT accuracy was 63.1% (95% CI 56.8-64.9%; p<0.01), while guessing was 51.4% (95% CI 0.483 - 0.544; p=0.01). In study 3 there was no significant difference between dynamometer-measured grip strength for true (mean 24.0 kg; standard error 2.1 kg) versus false (mean 23.8 kg; standard error 2.1 kg) statements (p=0.94). Testing for various factors that may have influenced kMMT accuracy failed to detect any correlations. Discussion In Studies 1 and 2 significant differences were found between accuracy in identifying verity of spoken statements using kMMT compared to both chance and guessing. Furthermore, the practitioner appears to be an integral part of the kMMT dynamic because when removed, no significance is achieved (Study 3). The main limitation of these studies is its lack of generalizability to other applications of kMMT. Conclusion kMMT when performed by a practitioner can distinguish true from false statements significantly more often than would be expected by chance alone. References 1. Martin, E.G. and R.W. Lovett, A method of testing muscular strength in infantile paralysis. Journal of the American Medical Association, 1915. LXV(18): p. 1512-3. 2. Walther, D.S., Applied Kinesiology: Synopsis. 2nd ed. Vol. 1. 2000, Pueblo, CO: Systems DC. 3. Bohannon, R.W., Manual muscle testing of the limbs: Considerations, limitations, and alternatives. Phys Ther Pract, 1992. 2(1): p. 11-21. 4. Cuthbert, S.C. and G.J. Goodheart Jr, On the reliability and validity of manual muscle testing: A literature review. Chiropractic and Osteopathy, 2007. 15. 5. Schmitt Jr, W.H. and S.C. Cuthbert, Common errors and clinical guidelines for manual muscle testing: "The arm test" and other inaccurate procedures. Chiropractic and Osteopathy, 2008. 16. 6. Teuber, S.S. and C. Porch-Curren, Unproved diagnostic and therapeutic approaches to food allergy and intolerance. Current Opinion in Allergy and Clinical Immunology, 2003. 3(3): p. 217-221.
Anne M Jensen1 DC ICSSD MSc DPhil Candidate • Richard J Stevens1MSc PhD • Amanda J Burls1MBBS MSc FFPH
1University of Oxford, UK Correspondence: anne.jensen@wolfson.ox.ac.uk
Healthcare practitioners have been using muscular strength testing to assess the
integrity of the neuromusculoskeletal system since early last century.1Since then,
its use has broadened, and now it is estimated that over 1 million practitioners use
kinesiologystyle manual muscle testing (kMMT) to evaluate a wide variety of
conditions. However, its clinical validity has yet to be firmly established.
A number of kMMT techniques have been developed that assess a patient’s
response to semantic stimuli.24Monti et al. found that following the speaking of
true statements, a muscle was able to resist significantly more force compared to
after speaking false statements.5They found that speaking true statements
resulted in a “strong” kMMT response, while speaking false statements resulted in
a “weak” kMMT response.5Reported here are the results of a series of 3 studies
of the diagnostic test accuracy using kMMT to distinguish true statements from
false, under varying conditions: Study I used different levels of practitioner
blinding, Study II repeated Study I blinding the practitioner throughout, and Study
III replaced practitionerapplied kMMT with gripstrength dynamometry.
BACKGROUND
1.MartinEG,LovettRW.Amethodoftestingmuscularstrengthininfantileparalysis.JAMA 1915;LXV(18):15123.
2.Walthe rDS.AppliedKinesiology:Synopsis.2nded.Pueblo,CO:SystemsDC,2000.
3.Thie J,Thie M.Touc h forhealth:Apracticalguidetonaturalhealth.Camarillo(CA):DeVorss Publications,2005.
4.WalkerS.NeuroEmotionalTechnique®CertificationManual.Encinitas(CA):NeuroEmotionalTech n iq ue , Inc.,2004.
5.Monti DA,SinnottJ,Marchese M,KunkelEJS,Greeson JM.Muscletestcomparisonsofcongruent
andincongruentselfreferentialstatements.PerceptMotSkills 1999;88(3):101928.
6.PollardH,LakayB,Tu cke rF, Watso nB,BablisP. Interexaminer reliabilityofthedeltoidandpsoas
muscletest.JManipulativePhysiolTher 2005;28(1):52.
7.CarusoW,Leisman G.Aforce /displa cement analysisofmuscletesting.PerceptMotSkills 2000;
91(2):68392.
REFERENCES
AIM
ToestimatetheaccuracyofusingkMMTtodistinguishtruestatementsfrom
falsestatements,comparedtousinggripstrengthandguessing.
Developingtheevidenceforkinesiologystyle
manualmuscletesting:
Designingandimplementingaseriesof
diagnostictestaccuracystudies
METHODS
FIGURE2– StudyMethods:(A)StudyIMethods,(B)StudyIIIMethods.[NOTE:MethodsforStudyIIare
identicaltoStudyIbutwithoutPractitionermonitor.]
A. B.
kMMT practitioners and kMMTnaïve test patients (TPs) were recruited. For
participant flow, see Figure 1. TPs were shown pictures (via computer) and
instructed (via headset) to make simple true or false statements about the
picture, after which the muscle test was performed. In all 3 studies, the
reference standard was the statements’ actual verity, in Studies I & II, the
index test was kMMT, and in Study III, the index test was gripstrength (kg).
In Study I each practitioner performed 40 MMTs and 40 guesses (without
using kMMT). Study II replicated Study I, and Study III removed the
influence of practitioners by using a gripstrength dynamometer to measure
muscle strength. In addition, in Studies I & II, a control condition was
enacted where the practitioner was asked to guessed the verity of the TP’s
spoken statement. See Figure 2 for pictorial descriptions of study methods.
FIGURE1Generalsummaryofmethodology:StudiesI,II,III
InStudiesIandIIsignificantdifferenceswerefoundbetweenaccuracyin
identifyingverityofspokenstatementsusingkMMTcomparedtochance.
Furthermore,thepractitionerappearstobeanintegralpartofthekMMTdynamic
becausewhenremoved,nosignificanceisachieved(StudyIII).Themainlimitation
ofthesestudiesisitslackofgeneralizabilitytootherapplicationsofkMMT.The
broadrangeofkMMTaccuraciessuggeststhereismuchyettobelearnedabout
theskillsinvolvedandpossibleinfluencingfactors .
kMMTwhenperformedbyapractitionercandistinguishtruefromfalse
statementssignificantlymoreoftenthanwouldbeexpectedbychancealone.
SUMMARY
RESULTS
In Study I, 48 unique practitionerTP pairs were assessed, and kMMT was used to
correctly distinguish truth from falsehood in 69.3% (95% confidence interval 66.0
72.5%) of statements more often than by chance alone (p<0.0001). In Study II, 20
unique pairs were assessed, and kMMT was used to correctly distinguish truth
from falsehood in 63.1% (95% confidence interval 56.864.9%) of statements more
often than by chance alone (p<0.0001). In study 3 there was no significant
difference between dynamometermeasured grip strength for true (mean 24.0 kg;
standard error 2.1 kg) versus false (mean 23.8 kg; standard error 2.1 kg)
statements (p=0.4693). Contrary to previous studies67we found that the years of a
practitioner’s kMMT experience did not significantly correlate with a practitioner’s
kMMT accuracy, nor did the practitioner’s selfranked kMMT expertise. See Tables
1and2below.
... We are grateful to all study participants for their contributions, and for the support from Wolfson College (Oxford University), Parker University and those practitioners who offered the use of their facilities during data collection. Portions of this study have been presented in poster or abstract form at scientific conferences [51][52][53][54][55][56][57][58][59]. ...
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Background Manual muscle testing (MMT) is a non-invasive assessment tool used by a variety of health care providers to evaluate neuromusculoskeletal integrity, and muscular strength in particular. In one form of MMT called muscle response testing (MRT), muscles are said to be tested, not to evaluate muscular strength, but neural control. One established, but insufficiently validated, application of MRT is to assess a patient’s response to semantic stimuli (e.g. spoken lies) during a therapy session. Our primary aim was to estimate the accuracy of MRT to distinguish false from true spoken statements, in randomised and blinded experiments. A secondary aim was to compare MRT accuracy to the accuracy when practitioners used only their intuition to differentiate false from true spoken statements. Methods Two prospective studies of diagnostic test accuracy using MRT to detect lies are presented. A true positive MRT test was one that resulted in a subjective weakening of the muscle following a lie, and a true negative was one that did not result in a subjective weakening of the muscle following a truth. Experiment 2 replicated Experiment 1 using a simplified methodology. In Experiment 1, 48 practitioners were paired with 48 MRT-naïve test patients, forming unique practitioner-test patient pairs. Practitioners were enrolled with any amount of MRT experience. In Experiment 2, 20 unique pairs were enrolled, with test patients being a mix of MRT-naïve and not-MRT-naïve. The primary index test was MRT. A secondary index test was also enacted in which the practitioners made intuitive guesses (“intuition”), without using MRT. The actual verity of the spoken statement was compared to the outcome of both index tests (MRT and Intuition) and their mean overall fractions correct were calculated and reported as mean accuracies. ResultsIn Experiment 1, MRT accuracy, 0.659 (95% CI 0.623 - 0.695), was found to be significantly different (p < 0.01) from intuition accuracy, 0.474 (95% CI 0.449 - 0.500), and also from the likelihood of chance (0.500; p < 0.01). Experiment 2 replicated the findings of Experiment 1. Testing for various factors that may have influenced MRT accuracy failed to detect any correlations. ConclusionsMRT has repeatedly demonstrated significant accuracy for distinguishing lies from truths, compared to both intuition and chance. The primary limitation of this study is its lack of generalisability to other applications of MRT and to MMT. Study registrationThe Australian New Zealand Clinical Trials Registry (ANZCTR; www.anzctr.org.au; ID # ACTRN12609000455268, and US-based ClinicalTrials.gov (ID # NCT01066312).
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